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REPORT ON THE PARAMEDIC COMMITTEE
August 1975
Report by the Task Force on Commissions and Committees
Dr. Robert J. Downey, Chairman Anne S. Collins
Theodore S. Flier Mrs. Ray Kidd
Joseph A. Lederman Robert Ruchti, II
Dr. Warren H. Schmidt George Shellenberger
Other Commission Members
Maurice Rene Chez, Chairman Gustave R. Anaya
Muriel Pfaelzer Bodek Catherine Graeffe Burke
John D. Byork Dr. Carolyn L. Ellner
Jerry Epstein Milton G. Gordon Leo A. Majich
Jesse L. Robinson Larkin Teasley Bryan Walker
Commission Staff
Burke Roche1 Executive Secretary John J. Campbell1 Staff Specialist
Maxlynn Larsen, Secretary to Commission
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PREFACE
In April, 1975, the Board of Supervisors approved the
Economy and Efficiency Commission's report on the Committee on
Emergency Medical Care. That report contained recommendations
covering the role, responsibilities, principles of operation
and composition of the committee.
We also addressed the question whether the Paramedic
Committee should be consolidated with the Committee on
Emergency Medical Care. We concluded that it should not be,
primarily because the functions of the two committees are
incompatible. We also recognized that there are substantive
issues related to the operation of the Paramedic Committee.
We, therefore, stated that in a subsequent report we planned to
examine the composition and functions of the Paramedic
Committee. Our findings and recommendations are contained in
this report.
In conducting the study we have reviewed committee minutes
and files and other documents associated with the operation of
paramedic programs. We have also conducted over 70 interviews
with members of the Paramedic Committee, County officials, and
other participants and authorities in the paramedic field,
including fire chiefs, ambulance operators, hospital
administrators, and community college officials. (See Appendix
A for a list of persons interviewed.) We thank them for their
suggestions and assistance in the preparation of this report.
The conclusions and recommendations, however, are solely the
responsibility of the task force.
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TABLE OF CONTENTS
SECTION PAGE
Preface i
I. Findings and Recommendations 1
Development of Paramedic Programs 1 Need for the Paramedic Committee 2 Function of the Proposed Paramedic Commission 6 Recommendations 8
II. Problems and Controversy 13
Proliferation of Paramedic Programs-The Control Problem 13 County Conflict of Interest 16 Public vs. Private Interests 18
III. Objective, Responsibilities, and Scope of the Paramedic
Commission 21
Objective and Responsibilities 21 Scope of Commission Responsibilities 23
IV. Composition and Method of Appointment 26
Composition 26 Excluded Alternatives 28 Membership Limitations 30 Method of Appointment 30
V. Self-Governance 32
Appendix A - Persons Interviewed 33
Appendix B - The Wedworth -Townsend Act 38
Appendix C - Administrative Code, Article LXX, Los Angeles County Paramedic Committee 43 Appendix D - County Counsel Opinion Concerning the
Organization and Operation of the ParamedicCommittee, July 10, 1975 46
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I. FINDINGS AND RECOMMENDATIONS
This section summarizes the task force findings and presents
its recommendations. Later sections of the report explain our
reasoning in greater detail.
Development of Paramedic Programs
In 1967, the primary method of treating emergency patients in
Los Angeles was to deliver them to hospitals as quickly as
possible, with little or no care at the scene or during transport.
There were no paramedics. Public safety and ambulance personnel
were not trained to dispense definitive care or to describe patient
condition and act on physicians' orders. The public was not
generally aware of the probability that timely care of many heart
patients, accident victims, and other emergency cases could save
lives.
Now, in 1975, emergency patients in Los Angeles County are
treated at the scene by medical technicians - called mobile
intensive care paramedics - trained to describe the condition of
patients by radio or telephone to a physician or nurse at a base
station hospital and to act on the doctor or nurse's orders. The
program extends over nearly all of Los Angeles County and is
expected to be available throughout the entire County by January,
1976.
The County Fire Department provides paramedic services to 37
cities and the unincorporated area. Twenty-six other cities,
including Los Angeles, provide their own services. There are now
in the County nearly 800 paramedics manning 102 rescue squads.
They are supported by 25 base station hospitals and respond to
approximately 8000 calls per month.
The Board of Supervisors, particularly Supervisor Hahn,
provided the leadership and the resources to accelerate the
development and expansion of pre-hospital medical service
throughout the County.
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In 1970, following State legislation enabling Counties to
provide paramedic services, the Board, on motion of Supervisor
Hahn, established the Paramedic Committee to provide the County
guidance and support in the development of training programs
designed to assure a high level of quality. Under the leadership
of Dr. Walter Graf, who has been chairman of the committee since
its inception, the committee has provided a significant level of
guidance and support in the development of paramedic programs.
Paramedic services have saved countless lives and have markedly
improved the prognosis for thousands of patients.
Need for the Paramedic Committee
Despite these truly remarkable accomplishments, problems and
controversy remain unresolved. The existence of problems does not
reflect adversely on County officials and others whose creative
efforts have been responsible for the immense improvement in the
delivery of emergency medical care. Rather, such problems are
inevitable when innovative programs experience such rapid growth.
This is particularly true in the complex and fragmented
jurisdictional environment of Los Angeles County.
We believe the problems and controversy can be resolved. In
order to understand the role we recommend for the Paramedic
Committee in the resolution of these problems, it is necessary to
understand the nature of the issues which confront the County, the
Paramedic Committee, and other public and private agencies involved
in paramedic programs.
The Control Problem - The programs have developed so rapidly
and proliferated so extensively that effective management and
control of the system has not kept up with its growth. There are
27 separate paramedic programs provided by various jurisdictions in
Los Angeles County. Each has its own
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management structure, policies and procedures. The Department of
Health services is making progress in developing more effective
standardization and quality control. However, the programs are
still expanding. There is urgent need for the department to
complete development of an equitable and comprehensive control
system.
County Conflict of Interest - State law assigns to counties
the responsibility for establishing standards and controlling
paramedic programs by certifying paramedics and training programs
and contracting with hospitals. (The Wedworth-Townsend Act of 1970,
as amended. See Appendix B.) Los Angeles County also provides
services and training through the Fire Department, the Sheriff, and
the Department of Health Services. A number of authorities whom we
interviewed stated that the County has adopted arbitrary and
piecemeal standards that are advantageous to the County as a
provider but interfere unfairly with the ability of municipalities,
community colleges, and ambulance companies to provide services or
training.
Our findings indicate that in some instances the department
and the Paramedic Committee have adopted standards on a judgmental
basis in the absence of performance data and without sufficient
public review and debate. In the period of rapid expansion of the
programs, it was necessary to adopt standards. It is true, as we
have indicated, that they are piecemeal. In addition, like any
judgmental standards they may be criticized as arbitrary. In some
cases, there is cause also to question whether they are free of
bias toward large governmental providers.
We have found no evidence, however, of improper motivation in
these actions. Under the circumstances, the concern of the
department and the committee was to maintain quality treatment and
adequate safeguards to protect lives.
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Regardless of the merits of these criticisms, the significant
point is that the County lacks credibility, when as the provider of
services, it adopts standards and controls which regulate the
ability of others to provide similar services. Thus the County of
necessity has a conflict of interest when it acts as both a
provider and controller of services.
Public vs. Private Interests - A controversy has developed
over the appropriate roles of the public and private sectors in
providing paramedic services. One debate centers on the question
whether fire department paramedics should transport patients to the
hospital after treatment in the field or continue - as many do now
- to call on private ambulance companies for transportation. A
related debate centers on the question whether private ambulance
companies should participate at all.
In the past, the combined circumstances of rapid expansion of
programs and the absence of solid scientific data forced everyone
involved, including the County and the Paramedic Committee, to make
decisions or take positions based on untested assumptions. At
present the department is making progress in acquiring and
analyzing the appropriate data. Nevertheless, the controversy is
growing.
Essentially, the origin of these issues is the fragmented
management of emergency medical services. Paramedic programs,
which constitute a segment of these services, are particularly
weak in this area. The law governing paramedic services does not
provide for management; it merely enables counties to provide
services and to exercise some control. The problem is further
aggravated by the hybrid nature of paramedic services which involve
both rescue and health care. Rescue traditionally has been a
public safety function, provided in Los Angeles County by a host of
municipalities and private firms as well as
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County government. Health care, to the extent that it is a
governmental function, is provided principally by the County.
Some authorities contend that until some structure for
centralized management of emergency medical services is
established, there is little hope of resolving current problems.
We question this conclusion. While centralized management would
bring uniformity and standardization to the system, it is difficult
to predict when and how it may be accomplished, in view of the
current maze of public and private agencies involved.
The problems, however, are current and the need for solution
is urgent. In the absence of centralized management what is needed
to resolve them is a comprehensive system of standards and quality
control based upon systematic study and research. As we have
indicated, the Department of Health Services is engaged in
developing such a system.
This control system will not be effective unless it gains a
high degree of acceptance from those affected, including cities,
fire departments, training institutions, ambulance companies,
paramedics, nurses, hospitals, patients, and the patients'
physicians. Such acceptance can only be achieved if all these
elements of the community are assured that standards, methods and
procedures for which the County is responsible will not be
unilaterally imposed without an opportunity for public review and
discussion.
It is urgent, therefore, at this time that the County take
action to establish a mechanism for such public review. The
urgency of this need is demonstrated by the history of the
Paramedic Committee in recent years. Since 1973 those involved and
concerned with paramedic programs have brought a number of issues
to the committee for public review and resolution. The committee
has advised the Director of Health Services on these issues, even
though it has no
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legal jurisdiction to do so. The ordinance on the committee
specifies only that it will advise the Director of Health Services
"on matters relating to the training and certification of Mobile
Intensive Care Paramedics." (See Appendix C.)
We conclude that the Paramedic Committee should be reorganized
into a new Paramedic Commission to provide a properly constituted
legal body to meet this need.
Function of the Proposed Paramedic Commission
The new commission will serve as a public review and
arbitration board to insure that anyone having an interest in
paramedic programs has the opportunity to debate or appeal
controversial County decisions and policies. We do not mean that
the commission should assume the responsibility of the Department
of Health Services to develop and enforce a control system. To do
so would destroy the ability of the Board of Supervisors to hold
the department accountable for its actions. We do mean that the
commission should act for the Board of Supervisors to hear and
arbitrate matters in which others concerned with paramedic programs
differ strongly with the department.
The task force recommends that the commission report directly
to the Board of Supervisors. It would be inappropriate for the new
commission to report to the Director of Health Services. The
commission would lack credibility if It reported to the official
whose decisions it was reviewing.
This change in the reporting structure will not make the
commission's decisions 1ega11y binding on the Director of Health
Services. As we have noted, present State 1aw specifies that the
County Health Officer is the certifying authority for paramedic
training programs and paramedic candidates. The County Counsel
advises us that under the provisions of the current law (Appendix
B)
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the County cannot legally establish a commission whose decisions
are binding on the Certifying Officer. In addition, the County
Counsel informs us that the Board of Supervisors itself has no
authority to direct the Health Officer in making a decision on
certification or to overrule a decision once made, since the law
does not mention the Board.
If the Board of Supervisors wishes to invest itself and the
Paramedic Commission with binding authority, the County Counsel
states that it will be necessary to amend the Wedworth - Townsend
Act. We do not recommend that the Board seek such an amendment at
this time. The current Act expires in July, 1976. Work is already
under way throughout the State for a comprehensive revision. Any
amendment proposed by Los Angeles County should take other proposed
changes into consideration. Therefore, legislation to clarify the
authority of the Board of Supervisors should be deferred until the
1976 revision. In the interim, the Board, the commission, and the
department should determine from experience whether the change is
necessary.
At present, our conclusion is that the omission in the law
will not impair the ability of the Paramedic Commission to act as
an effective arbitration and hearing board. The necessity for
public review and debate and the desire of all providers of
paramedic services, including the County, for such an agency will
inevitably give strong authority to the commission's findings. In
addition, the change in reporting structure will enhance the
commission's credibility and effectiveness. Commission
effectiveness, however, will also require that County officials
inform those disagreeing with a County decision that they can
appeal to the commission.
It is important to note that although the commission will
report to the Board of Supervisors, it will communicate its
decisions to the Director of Health Services and other responsible
County officials. We would expect that
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the department would normally concur with the findings of the
commission. In the event that a decision of the commission
conflicts with a decision of the Director of Health Services, the
Director may choose either to concur with the commission or to
confer with the Board of Supervisors for final resolution.
We would anticipate little discord between the Department of
Health Services and the commission. As we have emphasized, it is
much to the advantage of the department to have its decisions
reviewed in public in controversial cases.
Recommendations
We recommend that the Board of Supervisors amend the present ordinance (Article LXX of the Administrative Code) to dissolve the Paramedic Committee and establish by ordinance a Paramedic Commission. The new ordinance should contain provisions providing for the following:
Objective of the Commission
To promote, within a framework of fair treatment of all sectors of the community having an interest in providing paramedic training or services, uniform, high quality paramedic care to the people of Los Angeles County.
Responsibilities
The Board of Supervisors will appoint the Paramedic Commission and it will report directly to the Board. To meet its objective, the Paramedic Commission will perform the following functions:
1. To provide public review on any issue involving paramedic
services and training when requested by a County department, other sectors of the community, or on its own initiative.
2. To arbitrate, in the field of paramedic services and
training, differences between the Department of Health Services and other sectors of the community, including but not limited to municipalities, public safety agencies, community colleges, hospitals, private companies and physicians.
3. To hear appeals of decisions made by the Department of
Health Services on the following matters:
a. Decisions to establish and enforce policies, procedures, and standards to control the certification of mobile intensive care nurses and paramedics.
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b. Decisions to accept or reject proposals of any
public or private organization to initiate or modify a program of paramedic services or training.
4. To hear appeals of certification decisions by the
Department of Health Services and the certifying officer. 5. To review and advise the Board of Supervisors on County
action to propose, support or oppose State legislation and regulations affecting paramedic programs.
Scope
In performing the above duties, the commission's review authority will cover standards and controls governing the following subject matter:
1. All equipment, operations, and personnel controlled by
and controlling the performance of the paramedic team at the scene of an emergency and during transport.
2. Didactic and clinical curricula of paramedic training and
continuing education programs; screening of applicants; and testing, certification, recertification and internship of mobile intensive care nurses and paramedics.
3. Equipment and staffing of base station hospital emergency
departments which have an impact on the performance of paramedics in the field.
4. Any County legislative programs affecting the provision
of pre-hospital emergency care by mobile intensive care paramedics.
Composition
The commission shall have 10 members as follows:
1. A physician - Director of an emergency department in a
paramedic base station hospital not operated by the County
2. A physician - On the faculty of a university affiliated
major teaching hospital 3. A physician - A member of the full-time professional
staff of a County hospital 4. A physician - On the staff of a community, proprietary,
or voluntary hospital
5. A physician - In private practice
6. A lawyer
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7. An educator 8. A registered nurse 9. A public member 10. A public member
Appointment and Term of Office
The Board of Supervisors will appoint commission members for two-year terms upon nomination of two by each Supervisor. The Board should determine which of the following methods it prefers to use in assigning positions for nomination by individual Supervisors.
- Assignment by the Chairman of the Board, based on
consultation with other Board members - Assignment by lot
With either method the Board could elect to assign one physician to each Supervisor.
Qualifications of Members
Physicians - should have current experience in a field within the
scope of the commission's responsibilities, such as emergency medical care, critical care, or the training and utilization of paramedics;
- should be specialists in one of the following areas:
emergency medicine, cardiology, traumatology, neurosurgery, orthopedics, internal medicine, anesthesiology, or psychiatry.
Lawyer - should be a member of the California bar; - should have substantial experience participating in
adversary proceedings or hearing and adjudicating disputes;
- should have some background or experience in governmental
administrative law; - should have some background in medical, insurance, and
education law;
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- must not be litigating or otherwise actively involved in
any case involving paramedic base station hospitals, mobile intensive care nurses or paramedics, or providers of paramedic services, during his or her tenure on the commission;
- should not be a physician. Educator - should have current experience and advanced education in
curriculum development, standardization and documentation, or the design and validation of evaluation instruments, preferably in the health sciences;
- should not be a physician. Nurse - should have current experience in the guidance of mobile
intensive care paramedics or the operation of mobile intensive care programs;
- preferably has current or prior experience in the
provision of critical care; - currently works at a level of first line supervision in a
paramedic base station hospital. Public Members - should be knowledgeable and concerned about the delivery
of medical services to the public at large; - must not be medical or health professionals or providers
of paramedic services or support services such as training, equipment, or transportation.
Membership Limitations
- must not be County employees, except for the physician on
the County hospital staff and possibly the physician on the faculty of the major teaching hospital. In no case should the County physicians be employed in the Division of Emergency Systems in the Department of Health Services;
- must not be the owner or manager of any organization,
public or private, which furnishes paramedic services, training, equipment, or supplies;
- must not be a member of the Committee on Emergency
Medical Care;
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- must not be an employee of another member of the Paramedic
Commission; - must not be an official representative of a labor union
or federation whose members are directly involved in the provision of paramedic services.
Self-Governance - The commission shall appoint its own staff, upon
authorization of number, classification, and budget by the Board of Supervisors.
- The commission should establish internal operating
policies and procedures, consistent with the ordinance, covering such matters as the time and place of meetings, selection of officers, terms of office, obligations of commission members, structure of subcommittees or advisory councils, if any, and the general conduct of its business.
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II. PROBLEMS AND CONTROVERSY
This section expands on the problems and controversy discussed
in Section I.
Proliferation of Paramedic Programs - The Control Problem
Paramedics are field medical technicians, who operate outside
of the clinical and institutional environment which usually
supports other medical technicians as well as nurses and
physicians. The concept of systematic medical intervention in the
field, although well developed for military applications, is less
than a decade old for civilian populations.
As we indicated in Section I, paramedic services have
developed from an experimental base established in 1969 to nearly
full coverage of Los Angeles County in 1975. At present there are
27 separate paramedic programs provided by various jurisdictions in
the County. Each has its own management structure and method of
operation. For example, some cities train firefighters to be
paramedics, others contract with ambulance companies; some
transport patients, others contract with an ambulance company for
transportation.
The programs have developed and are operating in the absence
of a comprehensive system of quality control or standards. There
are historical reasons for this situation. In contrast to several
other newly developed medical technologies, there was no
professional tradition to provide conceptual support to paramedic
development, as for example the tradition of registered nursing
provided for licensed vocational nursing. Systematic development
was also hindered by opposition to the entire concept. There were
in the beginning many medical professionals who were opposed to the
provision of medical services in the field by non-physicians. To
some extent such opposition still exists.
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According to the basic legislation allowing public operation
of paramedic programs (see Appendix B), County government is
responsible for establishing standards and controlling paramedic
programs operated from County hospitals or hospitals with County
contracts.
The County has two major methods of controlling paramedic
services. The first is the certification process. Without
certification no individual can practice as a paramedic. To be
certified he or she must successfully complete a training program
which also must be certified. The legislation specifies that the
County Health Officer is the certifying authority. Therefore, the
County controls both the labor supply and the training for all
paramedic programs.
The second County control is the system of Emergency Aid
Program contracts - contracts with hospitals and ambulance
companies that insure that the County will pay for emergency aid
for indigent patients. Through these contracts, the County
controls, at least partly, the organizations which will provide
paramedic services.
With the proliferation of programs, a much more structured and
comprehensive system of control based upon systematic study and
research is clearly needed. The County, as we have stated, has now
established an Emergency Systems Division. While it therefore is
developing the resources needed to establish a comprehensive system
of controls, its efforts to do so have been and will continue to be
highly controversial. Its decisions influence the costs and
effectiveness of programs operated by independent political
jurisdictions and private firms. The decisions also will directly
affect the careers of the people involved and the lives of
patients.
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The control problem was highlighted in 1973 when Pasadena City
College applied for certification of a new training program for
paramedics. The college viewed its proposed program as a natural
extension of the health occupation training it already offered.
The program, however, differed in major respects from that
conducted by the County, and some County officials were strongly
opposed to it. Their opposition was not based on evidence that the
proposal failed to measure up to a standardized curriculum
incorporating performance objectives. No such curriculum existed.
Rather the opposition of County officials was based primarily on
their opinion that community colleges lacked teaching resources
equivalent to those in the County. Pasadena City College was able
to implement its program at that time only because it had the
opportunity to review its proposal in public with the Paramedic
Committee.
The Emergency Systems Division of the Department of Health
Services is now developing a standardized curriculum which will
serve as a rational and objective yardstick for selecting proposed
paramedic training programs and evaluating existing ones.
Standardization and control is similarly needed for other elements
of the paramedic program. The Emergency Systems Division is also
working to develop a system to apply to these elements.
The Pasadena City College case demonstrated the need for
public review in the absence of a standardized system of controls.
As we have stated, however, the system itself is bound to be
controversial and will require public review for acceptance.
The Paramedic Committee has to some extent been performing
this review function. The problem is that it is not legally
authorized to do so.
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County Conflict of Interest
Through its control of the certification process, the County
can
- prevent any organization from offering training programs to compete with County training programs;
- prevent any organization from training and certifying
paramedics to operate a paramedic service;
- adopt standards of training, certification and operation which are preferential to the County's method of providing services;
- adopt standards which are prohibitively costly for smaller units of government or private operators, thus preventing them from providing paramedic services.
The County not only controls but also provides paramedic
services and training. In unincorporated territory and in contract
cities, County fire-fighters are the paramedics. The Sheriff also
employs paramedics for search and rescue operations. The County's
major teaching hospitals, Harbor General Hospital and the County
USC Medical Center, offer paramedic training.
Thus, other potential providers of service, such as
municipalities, community colleges, proprietary hospitals, and
ambulance companies, have found that to begin to provide service,
they must obtain the approval of an organization that competes with
them - Los Angeles County government.
As we noted in Section I, in this situation the County of
necessity has conflict of interest. The potential is high that the
other providers of service will allege that the standards adopted
by the County are arbitrary and are designed merely to obstruct the
provision of services and training by others. We have, in fact,
during the course of our study heard such allegations. Two
standards adopted and enforced in the past illustrate this point.
For example, the County has established the requirement that
before an individual can be admitted to a paramedic training
program he or she must
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be employed by a sponsoring ambulance company or fire department.
One may ask the question - why paramedics? There are no comparable
governmental standards restricting any person's freedom to
undertake training as a physician, nurse, respiratory therapist,
radiological technician, or similar vocation. While there may be
valid reasons to justify the County policy, such as the limited
capacity of existing training programs, it seems clear that the
possibility of the policy favoring large tax-funded organizations
like the County, makes imperative public debate and review of such
policies.
Even when a standard has been accepted as fair and practical,
it may still be susceptible to abuse and manipulation. The County,
for example, requires that each paramedic complete an internship of
twenty shifts of twenty- four hours with a working paramedic rescue
squad prior to certification.
The primary purpose of internship is to give the trainees some
basic field experience before they assume operating responsibility.
The problem is that the number and types of rescue calls
encountered in twenty shifts is strongly dependent upon the service
area of the unit to which the trainee is assigned. Consequently,
those who centrally administer the assignments control the quality
and effectiveness of internships.
While we can cite no evidence that the County has abused its
authority to assign internships, the possibility that it could do
so clearly reflects the need for impartial review of assignment
methods and resolution of disputes if they arise.
These are two examples of standards which the County has been
enforcing and which some authorities allege are unfair. Others
could be cited.
Regardless of the merits of these allegations, the County
lacks credibility, when, as a provider of services, it adopts
standards and controls which
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restrict the ability of others to provide similar services. Again,
we conclude there is a compelling need for public debate and review
before some agency which is free of conflict of interest and can
objectively arbitrate differences and disputes when they occur.
Public vs. Private Interests
Although paramedic programs to date have been widely acclaimed
and have received a broad base of public support, a controversy has
developed over the appropriate roles of the public and private
sectors in the provision of services.
As we noted in Section I, the debate centers on the use of
private ambulance companies. In particular, the controversy
involves the establishment of standards for determining when an
ambulance company qualifies to enter the field, and if it does, the
manner in which it should share responsibility with governmental
units. Some companies allege that present County standards create
a bias toward approving governmental programs which utilize
firefighters in a dual role as paramedics and ambulance companies
only in the role of transportation.
There is some evidence that County standards have had a
preferential effect, if not intent. At present, 24 of 26 cities
providing their own paramedics use firefighters, and two, Los
Angeles and Pasadena, use civilians employed in the fire
department. Only four use an ambulance company for first response
service. In addition, County firefighters serve 37 other cities as
members of the Consolidated Fire Protection District.
The County requires an ambulance company applying for
certification of its service to limit the service of a unit to a
contiguous geographic area containing a specified number of people
and not covered by a fire department
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unit. In addition, before a company can operate a paramedic unit
for emergency medical response, the County requires the company to
have commitments that the city governments of the area it serves
will use the service. To meet such standards, a company may have
to forego any consideration of achieving economies of scale because
of the limitation of geographic boundaries.
To date, public provision of service through local fire
departments has seemed highly advantageous. However, a number of
local jurisdictions have recently begun to compare the costs of
public and private services for similar levels of quality. Some
are finding that the use of private providers may have a cost
advantage. Others, such as Los Angeles City, have chosen to
provide their own service using civilians.
It is not our intention here to argue the pros and cons of
public vs. private provision of paramedic services. Our concern
rather is that in the controversy over this issue there is little
factual evidence to support standards and controls adopted in the
past. The result has been that everyone involved, including the
County and the Paramedic Committee, have been forced to make
decisions and take positions based upon questionable assumptions.
For example, it is not necessarily true, as widely believed,
that use of firefighters as paramedics is a cost free use of idle
labor. First, fire departments can be penalized by the insurance
grading process when firefighting manpower is used for paramedic
rescue work. Second, labor is needed in the station for routine
overhaul and maintenance activities. If the incidence of rescue
calls is high, this labor must be replaced. For these reasons, a
number of fire authorities reported to us that they will require a
subsidy from the County to continue providing paramedic services.
Thus, a number of cities are considering a change to contracting
with ambulance companies for basic emergency service.
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Again what is needed is a comprehensive system of controls and
standards subject to public debate and impartial review.
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III. OBJECTIVE, RESPONSIBILITIES AND SCOPE
OF THE PARAMEDIC COMMISSION
The responsibility for which the Paramedic Committee was
established - to advise the Director of Health Services on matters
relating to paramedic training and certification - has not been a
principal function of the committee for the past several years.
Our conclusion, as presented in Section I, is that a new Paramedic
Commission should be created. We are recommending the change from
"committee" to "commission" to emphasize that the role and scope of
the new commission differ substantially from those of the present
committee.
Objective and Responsibilities
The objective and responsibilities of the new commission are
designed specifically to meet the need for a mechanism to insure
public review of quality control decisions for paramedic programs.
As we pointed out in previous sections, the demand for public
review of County decisions has been so strong that the current
Paramedic Committee has acted to meet the need without explicit
legal authority in the absence of any other agency authorized to do
so.
In contrast to the original committee, the new commission will
not make certification recommendations to the department. We
believe that as the responsible legal authority, the Department of
Health Services should be held accountable for certification of
paramedic candidates and training programs. To be certified,
paramedic candidates will be required to pass standardized
examinations. Proposed training programs will be required to
satisfy criteria incorporated in a standardized curriculum.
Similar standardization will need to be established for continuing
education, recertification, and decertification.
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Thus, under our proposal the department will be fully
accountable for certification decisions. As we have emphasized,
what is needed is an appropriate avenue of appeal for those who
dispute these decisions. This is the role we assign to the new
Paramedic Commission. Since it will be acting as a review board
when those involved appeal decisions, it would not be appropriate
for it to participate in the original decision-making.
The control system will also incorporate performance standards
to regulate the quality of such other elements of paramedic
programs as drugs, equipment, and supplies. For these elements too
the commission will serve as an avenue for arbitration and appeal.
We should point out that the Wedworth-Townsend Act will expire
in July, 1976, and is now being reviewed for revision at that time.
Consequently, paramedic programs are now undergoing evaluation
throughout the State. Whatever the outcome, it is reasonable to
assume that the roles of the State, counties, and other providers
of service will be clarified by new legislation. We have not,
therefore, delineated in detail the subject matter of the control
system which the County may be required to develop and operate.
Under present legislation, the County has required deployment
of two paramedics per unit. It is not certain under future
legislation to what extent counties will be responsible for
standards of operation which specify resource allocation and
personnel deployment involving the management of programs by
municipalities, fire departments, and other providers. We believe
that whatever the role of the County becomes, it should be
administered by the Department of Health Services, with the
Paramedic Commission acting as an appeals board.
Clearly the responsibility we propose for the commission is
substantial. But, as we have emphasized repeatedly, the Department
of Health Services, because
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of its conflict position as both a provider and a regulator of
paramedic services, should not make these decisions without giving
those affected an opportunity for public debate, arbitration and
appeal.
We should also note that the hearing process of the commission
is not a passive one. In the course of a review of some decision
or set of standards, the commission may wish to recommend
alternatives to the County 's proposals.
The functions of arbitration of differences and hearing
appeals which we recommend for the Paramedic Commission could not
appropriately be performed by the Committee on Emergency Medical
Care. The Committee on Emergency Medical Care has two principal
functions. The first is to advise the County in the establishment
of policies, programs and standards for emergency medical care
services, including paramedic services. The second is to evaluate
the system and its impact as the County develops it. Consequently,
this committee could not act as an objective and credible hearing
board for arbitration and appeals, since it is a principal
participant in the development of the County's system.
The task force concludes that the Committee on Emergency
Medical Care cannot properly perform the responsibilities we
recommend for the Paramedic Commission.
Scope of Commission Responsibilities
Paramedic programs are only one part of a complex and far-
reaching system of emergency medical care. Many people and
agencies, in addition to the paramedics at the scene, are directly
involved: the doctors and nurses at the base hospital who instruct
the paramedics over the radio; the doctors and nurses at the
receiving hospitals who prepare for patient admission; the police,
firefighters, and ambulance attendants at the scene. Many others
are involved in the care of the patient, but with less impact on
paramedic performance before
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hospital admission: the staff of the emergency room in the
receiving hospital; the staff of the critical or intensive care
units to which the patient may be taken; the patient's physician
and family.
The system of emergency medical care will in the future
involve certain technicians other than those now designated
paramedics. Today's paramedics are trained to a level of
proficiency beyond advanced first aid. The advanced first aid
level has been designated EMT-I (Emergency Medical Technician I);
paramedics have been designated EMT-II. State and other agencies
are developing criteria for the training of EMT-III's and EMT-IV's.
The concept is that EMT-III's will provide more advanced field
treatment and assist in emergency rooms, while EMT-IV's will act as
physician's assistants in emergencies.
Criteria for doctors and nurses involved in emergency care are
also being developed.
There is a question, then, of where the responsibility for
local quality control in these fields should reside. Thus it is
important to delineate the scope of the new commission's
responsibilities in order to determine what decisions made by the
Department of Health Services come within the province of the
commission. (See Section I, p. 9.)
Since a system of standards and controls will be needed to
insure quality of service in all areas of emergency medical care,
it is reasonable to consider defining the scope of the commission's
responsibilities to include these areas. However, it is not clear
that the County would find itself in a similar conflict position in
regulating these other areas. Moreover, the concepts in many of
these other areas are not at present well developed. Consequently,
it is difficult to determine what role, if any, the commission
should have in their regulation.
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If in the future it is determined that there is a need for a
hearing board in other areas of emergency medical care, the County
should consider expanding the scope of the Paramedic Commission,
rather than creating separate commissions. We would caution the
Board of Supervisors, however, that the amount of work that will be
required of the Paramedic Commission in the paramedic area alone is
bound to be substantial for the next several years. We think it
wise, therefore, to limit the scope of the commission at this time
to areas which have a direct impact on the quality of paramedic
services.
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IV. COMPOSITION AND METHOD OF APPOINTMENT
The primary purpose of the Paramedic Commission is to act as
an arbitration and appeals board in order to insure both high
quality paramedic services and fair treatment of all sectors of the
community having an interest in providing these services. The
commission, therefore, should be structured to incorporate the
expertise required to understand, analyze and judge the issues
coming before it. At the same time, if the commission is to have
credibility as an impartial hearing body, its members must be as
free as possible from conflict of interest.
To some extent these two criteria are conflicting. That is
anyone who possesses experience and expertise in paramedic training
and procedures is almost bound to have an interest which presumably
at some time could impair his or her objectivity.
Our purpose in determining the membership for the commission
was to balance as much as possible expertise and freedom from
conflict. The recommended composition is designed to provide a
balance of points of view, broad representation of the community,
and the skills or expertise which will contribute to the decision-
making functions of the commission. (See Section I, pp. 9-10.)
Composition
The Paramedic Committee was originally composed entirely of
physicians. We think physician expertise will continue to be
essential to the operation of the Paramedic Commission, since its
primary objective is quality control of paramedic programs.
Physicians have the most to contribute in this area. They also
represent the major interest group because it is their patients who
are involved.
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However, in contrast to our recommendation regarding the
Committee on Emergency Medical Care, the primary consideration in
selecting physician members should be their institutional
affiliations rather than their specialties.
The commission will be making decisions and resolving disputes
involving the effects of quality control standards on the costs of
public and private providers of service. The outlook of physicians
from the large public hospital, the community-based private
hospital, and the teaching hospital will contribute a necessary
balance of the private and public sectors. The viewpoint of a
physician in a paramedic base station and that of a practicing
physician with no particular institutional affiliation should
further enhance the balance on the commission.
We recommend that one member be a lawyer. The purpose of the
lawyer on the commission is not to replace County Counsel. The
advice of the County Counsel will always be available to the
commission, and would take precedence on any point of law.
Nevertheless, the commission will be responsible for providing an
impartial forum for hearing the divergent views of various sectors
of the health services community. A lawyer's training and
experience should contribute substantially to the commission's
effectiveness in insuring equitable and balanced debate.
We recommend that one member be an educator. The commission
will be considering highly technical educational questions
requiring an understanding of the best current educational practice
involving curricula, testing, course structures, and training
programs.
We recommend that one member be a registered nurse with mobile
intensive care experience employed by a paramedic base station
hospital. The direct experience of such nurses with paramedics
acquaints them with the strengths and weakness of paramedic
training. In addition, their insight into the ways that
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paramedic services complement nursing and its responsibilities will
assist the commission in its deliberations, especially with regard
to the opposition of nursing groups to the paramedic concept.
We recommend that two members be public members, who are not
medical or health services professionals or providers of such
services. Public members contribute to specialized commissions of
this type in two ways. First, they bring the perspective of
detached but potentially affected people to the commission.
Second, they tend to question the tacit assumptions of the
professionals on the commission. Thus, they should further
strengthen the commission's impartiality.
Excluded Alternatives
We have elected to recommend a composition which does not
include members suggested by some authorities: The most important
of these are a fire chief, an ambulance company operator, a working
paramedic, and a hospital administrator. There are several reasons
for each of these omissions. In general, we have tried to avoid
recommending representation which 1) would unnecessarily increase
the size of the commission or upset its balance, and 2) would
create a potential conflict of interest.
For example, the recommended composition does not include the
County Forester and Fire Warden, a member of the current Paramedic
Committee. Including the Forester and Fire Warden would require,
for balanced representation of both public and private operations,
adding representatives of a large city fire department, a small
city fire department, and private ambulance companies. All of
these, like the Forester and Fire Warden, are providers of
paramedic services. In addition, a representative of the Sheriff
would have to be considered,
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since he employs paramedics for his search and rescue operations.
The resulting addition of four or five more non-physician members
would upset the overall balance of the commission.
Moreover, each of these members would have a potential
conflict, since each has a direct interest in the provision of pre-
hospital care and the costs associated with the level of quality to
be considered by the commission. For these reasons the task force
concludes that none of these providers of paramedic services should
serve on the commission.
Some of the authorities we interviewed have said that
including a working paramedic would enhance the commission's
effectiveness by adding the point of view of those whose
performance, training, and careers will be directly affected by its
actions. As others have pointed out, however, a working paramedic
on the commission is likely to have conflicts which will impair his
or her objectivity. First, decisions will be considered that will
have a personal impact on the paramedic, thus weakening the
impartiality with which the commission should operate. Second, the
commission will consider matters on which the paramedic's superiors
may have strong positions. Whatever the point of view of the
paramedic, he or she would be in a difficult position to express it
without obtaining the approval of a superior.
The absence of a hospital administrator from our
recommendation is based primarily on the scope of commission
operation. The commission will be primarily concerned with pre-
hospital care. It will be concerned with hospitals only to the
extent that their activities have a direct impact on paramedic
operations in the field.
With respect to all such alternatives, we should emphasize that it is neither necessary nor desirable
for a commission to include within its membership people with all the various skills that may possibly
contribute to its work.
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Excluding some types of expertise does not preclude the Commission
from seeking advice from such experts, nor will it preclude anyone
from requesting a hearing or giving testimony.
Membership Limitations
The Paramedic Commission will be considering highly
controversial issues that have an impact on the lives of patients
and on the careers of medical technicians. Its work will be a part
of the decision-making process of County government. Therefore,
not only its expertise, but also its credibility and prestige in
the community are important to its success. All of the constraints
on membership are based, in particular, on the need for
credibility. Consequently, we have recommended strong restrictions
in the general area of conflict of interest. (See Section I, pp.
11-12.)
The problem with such restrictions, as we noted in the
introduction to this section, is that they can limit the range of
the Board's search for expert members. Too strong a limitation -
for example, excluding anyone with a professional or financial
interest - would result in excluding all necessary expertise. The
limitations on membership therefore are designed to exclude only
those individuals who would clearly encounter a conflict of
interest, that is, those with a major career, professional or
financial interest that is likely to be affected by commission
decisions.
Method of Appointment
The commission will hold hearings on issues which otherwise
would require public debate before the Board of Supervisors. It
should be structured therefore to effectively represent the Board.
In contrast to the Committee on Emergency Medical care, which
has the highly technical job of systems evaluation, the Paramedic
Commission will function
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Primarily as arbitration and appeals board. Therefore, we have
proposed that the Board of Supervisors select members of the
Paramedic Commission directly, rather than through nominations by
organizations that are in a position to locate the expertise needed
for technical evaluation of the system.
As the ordinance provision which we recommend states (see
Section I, p. 10), each Supervisor will nominate two members for
appointment by the Board. We have not specified a method by which
the Board should determine which positions are assigned for
nomination to individual Supervisors. We have suggested, however,
that it could be done either through assignment by the Chairman of
the Board or by lot. In either case the Board could elect to
assign one physician to each Supervisor.
Whatever the method, we urge the Board to give consideration
to the expertise which current members of the Paramedic Committee
possess in this area based on their years of experience serving on
the committee. We would also suggest that Board members consult
with each other regarding the nomination of physicians to insure a
balance of specialty fields, such as emergency medicine,
cardiology, traumatology and surgical specialties.
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V. SELF-GOVERNANCE
The ordinance we recommend specifies that the commission shall
adopt its own internal operating policies and procedures consistent
with the provisions of the ordinance. (See Section I, p. 12.) The
rules should cover time and place of meetings, selection of
officers, terms of office, obligations of commission members,
structure of sub-committees or advisory councils, if any, and the
general conduct of commission business.
The chairman of the current Paramedic Committee, Dr. Walter
Graf, was appointed to the chair by the Board of Supervisors when
the committee was established in 1970. The new Paramedic
Commission may choose to continue this practice or adopt some other
method of selecting its officers.
The ordinance also specifies that the commission will appoint
its own staff as authorized by the Board of Supervisors.
Experience can only determine what staff positions and
classifications will be required.
Daniel Freeman Hospital is now furnishing administrative and
clerical support to the present Paramedic Committee free of charge.
Since most of the information required by the new commission to
perform its duties will be presented to it in public hearings, and
since the present committee is already functioning in a similar
manner, we would conclude that additional staff requirements will
be minimal.
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APPENDIX A Persons Interviewed
Members of the Paramedic Committee Gail V. Anderson, M.D. Professor and Chairman, Department
of Emergency Medicine, County-USC Medical Center
J. Michael Criley, M.D. Chief, Division of Cardiology,
Harbor General Hospital Sister Frances Ellen, R.N. Nursing Administrator, Queen of the
Valley Hospital Walter S. Graf, M.D,. Clinical Professor of Medicine, Chairman University of Southern California
and Loma Linda University Julius W. Hill, M.D. Professor of Surgery, Charles R.
Drew School and Martin Luther King Hospital
David B. Homer, M.D. Associate Clinical Professor of
Medicine, University of Southern California
Richard H. Houts Forester and Fire Warden and Chief
Engineer, Los Angeles County John W. H. Sleeter, M.D. Director, Emergency Department,
Santa Teresita Hospital
Paul A. Teslow Administrator, Northridge Hospital County Employees (Not members of the Committee) John E. Affeldt, M.D. Medical Director,Department of
Health Services Gaylord E. Ailshie Director, Paramedic Services,
Division of Emergency Medical Systems, Department of Health Services
Richard B. Baird Division Chief, Program and Budget
Division, Chief Administrative Office
Morrison E. Chamberlin Chief Deputy Director, Department of
Health Services
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Robert Eskanos Principal Administrative Analyst,
Management Audit Division, Chief Administrative Office
R. T. Freeman Inspector, Sheriff's Department John Gelfuso Firefighter Paramedic, Station 3,
Consolidated Fire Protection District
Stanley Grant Administrator, Division of Emergency
Medical Systems, Department of Health Services
David L. Lemm Captain, Station 3, Consolidated
Fire Protection District Ben E. Matthews Chief, Operations Division,
Department of Forester and Fire Warden
Daniel D. Mikesell, Jr. Deputy County Counsel John P. O'Connor Deputy Director, Contracts and
Community Services, Department of Health Services
Jess Perez Firefighter Paramedic, Station 3,
Consolidated Fire Protection District
Ronald Pierce Firefighter Specialist, Station 3
Consolidated Fire Protection District
Nino F. Polito Division Assistant Chief, Operations
Division, Department of Forester and Fire Warden
Elliot Salenger, M.D., M.P.H. Medical Director, Division of
Emergency Medical Systems, Department of Health Services
Paul P. Schneider Division Assistant Chief, Operations
Division, Department of Forester and Fire Warden
Richard S. Scott, M.D. Director of Special Projects,
Department of Emergency Medicine, County-USC Medical Center
Paul G. Seehusen Deputy County Counsel Ronald D. Stewart, M.D. Director, Paramedic Training,
Division of Emergency Medical Systems, Department of Health Services
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Gerald Surfus Chief, Risk Management, Program
Evaluation Division, Chief Administrative Office
Liston A. Witherill Director, Department of Health
Services Others Brian G. Adlington President, Verdugo Hills Hospital Robert B. Andrews, Ph.D. Professor, Graduate School of
Management, UCLA Mrs. Colly Bakeman, R. N. Past Coordinator-Instructor, EMT
and Paramedic Program, Department of Nursing, Pasadena City College
Joseph N. Baker City Manager, City of Burbank Harry C. Bigglestone Chief Protection Engineer,
PacificRegion, Insurance Services Office
Rand Brooks Owner, Professional Ambulance
Company Inice Chirco, R.N., M.A., M.S. Chairman, Department of Allied
Health, Rio Hondo College Frank Clark Director of Professional Affairs,
Los Angeles County Medical Association
Mrs. Joan M. Davidson, R.N. Chairman, Department of Nursing,
Pasadena City College Joseph M. Dolphin President, Los Angeles County
Ambulance Association Charles Dovey Los Angeles MICU Paramedic,
MEDEVAC Paramedic Ambulance Inc. Raymond L. Eden Executive Director, American
Heart Association, Greater Los Angeles Affiliate
Walter Edwards, M.D. President, American College of
Emergency Physicians and Director, Emergency Room Daniel Freeman Hospital
Ida L. Frisbee Chairperson, Department of Human
Services, Compton College Winnie Hobbs Paramedic Coordinator, Education
Department, Daniel Freeman Hospital
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Dennis Jorgensen Vice President, Newhall Ambulance
Inc. George W. Kahl Fire Chief, City of Monrovia Glenn A. Langer, M.D. President, American Heart
Association, Greater Los Angeles Affiliate
Kenneth Long Chief Engineer, Fire Department,
City of Los Angeles John R. MacFaden Executive Vice President, Los
Angeles County Ambulance Association
John H. Mahaffey President, ANVAL Enterprises Inc. John W. Mahaffey Secretary-Treasurer, ANVAL
Enterprises Inc. Gene Mahoney Chief, Fire Department, City of
Arcadia George D. Morgan Captain, Paramedic Co-Ordinator,
Department of Fire,City of Long Beach
Muriel M. Morse General Manager, Personnel
Department, City of Los Angeles Gail Pleasance, R.N Instructor, Education Department,
Daniel Freeman Hospital J. Walter Schaeffer President, Schaeffer's Ambulance
Service Inc. Edward L. Schindler Assistant Director for Emergency
and Disaster Services, Hospital Council of Southern California
Joe G. Smith Chief, Fire Department, City of
Inglewood Leslie R. Smith Executive Director, San Pedro and
Peninsula Hospital John F. Sturges Chief, Fire Department, City of
Santa Monica Mrs. Mary Taylor, Jr. Chairman of the Board, American
Heart Association, Greater Los Angeles Affiliate
William Trautman Los Angeles MICU Paramedic,
MEDEVAC Paramedic Ambulance Inc.
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Robert B. White San Fernando Valley Area
Representative, Los Angeles County Federation of Labor, AFL-CIO
Robert F. Woehrmann Owner, AIDS Ambulance and
Medical Service Mrs. Betty Wright, R.N. Coordinator-Instructor, EMT and
Paramedic Program, Department of Nursing, Pasadena City College
Howard Zuck Assistant General Manager,
Personnel Department, City of Los Angeles
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APPENDIX B
HEALTH and SAFETY CODE
WEDWORTH-TOWNSEND ACT
MOBILE INTENSIVE CARE PARAMEDICS
1480. Pilot program
Any general acute care hospital operated by, or contracting with, a county may conduct a pilot program which provides services utilizing mobile intensive care paramedics for the delivery of emergency medical care to the sick and injured at the scene of an emergency, during transport to a general acute care hospital, while in the emergency department of the general acute care hospital until care responsibility is assumed by the regular staff of the general acute care hospital, and during training within the facilities of the sponsoring general acute care hospital. 1480.1 Pilot program
The training of mobile intensive care paramedics may only be conducted by a community college, college, university, or hospital that has a certificate of approval for its curriculum and training program from the county health officer of the county in which it is located. 1481. Definitions
As used in this article:
(a) "Mobile intensive care paramedics" means personnel who have been trained in the provision of emergency cardiac and noncardiac care in a training program certified by the county health officer of the county giving certification or a certified training program in another county that has been evaluated and approved by the county health officer of the county giving certification, and who pass the performance and written examinations required for certification by the officer as qua1ifed to render the services enumerated in this article in the county giving such certification.
(b) "Mobile intensive care nurse" means a registered nurse who has been certified by a county health officer as qualified in the provision of emergency cardiac care and noncardiac care and the issuance of emergency instruction to mobile intensive care paramedics.
(c) "Mobile intensive care units" means any emergency vehicles staffed by mobile intensive care paramedics or mobile intensive care nurses and equipped to provide remote intensive care or cardiac care to the sick or injured at the scene of medical emergencies or during transport to general acute care hospitals.
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(d) "Emergency department" means any department or separate area within a general acute care hospital which is staffed and equipped to provide emergency medical care to the sick or injured. 1481.1 Minimum training; experience
The training program for mobile intensive care paramedics shall consist of a minimum of 200 hours of didactic training, a minimum of 100 hours of clinical experience, and a field internship of at least 200 hours.
However, all or any portion of the required training program for a mobile intensive care paramedic may be waived by the county health officer of the county giving certification if the applicant passes the performance and written examinations required for certification or the appropriate portion of the performance examination. 1481.2 Program evaluation report
Each county conducting a pilot program pursuant to this article shall submit an annual report to the Legislature and to the State Department of Health, not later than January 31 of each calendar year, evaluating any such pilot program conducted at any general acute care hospital operated by the county or under contract with the county. The report shall include an evaluation of the competency and effectiveness of the performance by the mobile intensive care paramedics in their duties in staffing rescue units and in the rendering of medical and nursing care pursuant to this article. The report may include recommendations relating to the extension or modification of the provisions of this article. 1481.3 Courses of instruction and training; certification; fees;
reimbursement by federal funds Any county conduct a pilot program under this article may provide courses of instruction and training leading to certification as a mobile intensive care paramedic. Where such instruction and training is provided to public employees other than employees of the county or employees of the fire protection district within the county, a fee may be charged sufficient to defray the cost of such instruction and training. Where such instruction and training is provided to any other persons such fee shall be charged. However, such fee may be reduced to the extent of any federal funds obtained by the county for the purpose of providing such instruction and training.
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1482. Duties
• Notwithstanding any other provision of law mobile intensive care paramedics may do any of the following:
(l) Render rescue, first aid and resuscitation services. (2) Perform cardiopulmonary resuscitation and defibrillation. (3) During training and while caring for patients in the
sponsor general acute care hospital under the direct supervision of a physician or registered nurse, or while at the scene of a medical emergency where voice contact or a telemetered electrocardiogram is monitored by a physician or a certified mobile intensive care nurse where authorized by a physician, and where direct communication is maintained, upon order of such physician or such nurse:
(a) Administer intravenous saline, glucose or volume expanding agents or solutions.
(b) Perform gastric suction by intubation. (c) Perform pulmonary ventilation by use of esophageal
airway. (d) Obtain blood for laboratory analysis. (e) Apply rotating tourniquets. (f) Administer parenterally, orally or topically any of the
following classes of drugs or solutions: (i) Antiarrhythmic agents. (ii) Vagolytic agents. (iii) Chronotropic agents. (iv) Analgesic agents. (v) Alkalinizing agents. (vi) Vasopressor agents. (vii) Narcotic antagonists. (viii) Diuretics. (ix) Anticonvulsants. (x) Ophthalmic agents. (xi) Oxytocic agents. (xii) Antihistaminics. (xiii) Bronchodilators. (xiv) Emetics. (g) Assist in childbirth
1483. Liability for instructions given paramedics
No physician or nurse, who in good faith gives emergency instructions to a paramedic at the scene of an emergency, shall be liable for any civil damages as a result of issuing the instructions. 1484. Duration of article
(a) This article shall remain in effect only until July 1, 1976, and shall have no force or effect after that date.
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(b) On or before July 1, 1975, the State Department of Health shall submit to the Legislature a comprehensive report on emergency medical services in California. Such report shall include a thorough review and evaluation of the mobile intensive care paramedic pilot program authorized by this article and shall make specific recommendations on the following:
(1) Development of statewide coordination of emergency medical service systems, including appropriate communications Systems and equipment;
(2) Development of manpower certification standards for all types of emergency medical service personnel to include specifically the training and scope of practice requirements for the categories of ambulance personnel (E.M.T. I) and paramedics (E.M.T. II);
(3) Standards for local paramedic programs including location, qualifications for appropriate teaching institutions, performance standards, and the curriculum necessary for state accreditation of the local program; and
(4) Standards for the staffing and equipping of hospital emergency rooms.
(c) In developing such report, the department shall solicit the advice and recommendations of the Advisory Committee on Emergency Medical Services.
1484.1 Duration of article
During the clinical internship portion of the training program specified in Section 1481.1, mobile intensive care paramedic interns shall be supervised continuously by a physician or registered nurse.
During the field internship portion of the training program specified in Section 1481.1, mobile intensive care paramedic trainees may perform all the services enumerated in this article, provided that they are supervised and accompanied by a certified mobile intensive care paramedic, a physician, or a mobile intensive care nurse. l484.2 Duration of article The county health officer shall establish criteria necessary to maintain certification as a mobile intensive care paramedic or a mobile intensive care nurse including, but not limited to:
(a) A formal program of continuing education (b) Continuous service as a mobile intensive care paramedic
or a certified mobile intensive care nurse.
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(c) Retesting at two-year intervals, which shall include a performance examination and may include written examinations and oral examinations.
1484.3 Duration of article
No agency, public or private, shall advertise or disseminate information to the public that the agency provides paramedic rescue or paramedic ambulance service unless that agency does, in fact, provide mobile intensive care units on a continuous 24-hours-per-day basis. If advertising or information regarding the agency's paramedic rescue or paramedic ambulance service appears on any vehicle it may only appear on those mobile intensive-care-unit vehicles utilized solely to provide service on a continuous 24-hours-per-day basis.
1484.4 Duration of article
It shall be a misdemeanor for ambulance personnel to impersonate or refer to themselves as paramedics unless the person has been certified as a mobile intensive care paramedic and currently maintains that certification. 1485. Short title
This article shall be known and may be cited as the Wedworth-Townsend Paramedic Act. It is the intent of this article to respond to the critical shortage of professionally trained medical and nursing personnel for the fast, efficient medical care of the sick or injured at the scene of a medical emergency, during transport to a general acute care hospital, and in the emergency department of the general acute care hospital until care responsibility is assumed by the regular staff of the general acute care hospital. Improved emergency medical service is required to reduce the mortality and morbidity rates during the initial treatment phases of the onset of an acute illness or following an accident. Within the goals of this act is the provision of the best and most efficient and economical delivery of emergency medical care. This has been prepared for your use by the office of State Senator James Q. Wedworth. It is the complete Wedworth-Townsend Paramedic Act effective January 1975, and includes the original act and subsequent legislation.
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APPENDIX C ORD. NO. 4099 274 - 10,846 Eff. 3-22-74
ARTICLE LXX LOS ANGLLES COUNTY PARAMEDIC COMMITTEE
(10,846 3-22-74) Sec. 1651. CREATION. There is hereby created the Los Angeles County Paramedic Committee, hereinafter referred to in this Article as the "Committee," which shall supersede the Los Angeles County Paramedic Committee heretofore established pursuant to Board Order. Sec. 1652. MEMBERSHIP. The Committee shall consist of ten members and one ex officio member. All members, except the ex officio member, shall be appointed by the Board. Eight of the members shall be licensed to practice medicine in the State of California. The five physicians currently serving on the Los Angeles County Paramedic Committee, heretofore established pursuant to Board Order, shall be deemed members of the Committee. The ex officio member shall be the County Forester and Fire Warden.
Three additional physicians shall be selected as follows: (a) One shall be a physician actively engaged in the practice
of emergency medicine in a paramedic base hospital in the County of Los Angeles and be a current member of the American Col1ege of Emergency Physicians.
(b) One shall be a physician in charge of the emergency department of a paramedic base hospital in the County of Los Angeles.
(c) One shall be nominated, subject to Board approval, by the Medical Advisory Council of the City of Los Angeles and be currently engaged in practice in a paramedic base hospital in the County of Los Angeles.
The remaining two non-physician members shall be selected as follows:
(d) One shall be nominated by the Hospital Council of Southern California, subject to Board approval, and be currently employed as an Administrator of a paramedic base hospital in the County of Los Angeles, He shall not, however, be from the same hospital as any of the physicians appointed pursuant to sub-paragraphs a, b and c above.
(e) One shall be nominated by the Directors of Nursing Council, subject to Board approval, and be currently employed as a registered nurse in a paramedic base hospital in the County of Los Angeles, whose specialization is emergency care in an emergency setting, such as a trauma center, critical care unit, or intensive care unit.
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ORD. NO. 14099 274 - 10,846 Eff. 3-22-74 Sec. 1653. TERMS. Each member or the Committee, except the ex officio member, shall serve for a term or one year from the date of appointment and until his successor is appointed and qualifies. For those physicians who are deemed members pursuant to Section 1652 of this Article, the date of appointment shall be the effective date or this Article. All appointments are subject to the right of the Board to remove any such member at any time at its pleasure and also subject to the provisions of Section 39.5 and all other applicable provisions of this Ordinance. In the case of the death, resignation, or removal of any member by the Board or pursuant to Section 39.5, or otherwise, his successor shall serve for the remainder of the unexpired term. Sec. 1654. COMPENSATION. The compensation of members of the Committee and the Advisory Council shall be as provided from time to time in the current salary ordinance of the County of Los Angeles. In the absence of any provision therefor in said current Salary Ordinance, the members of the Committee and the Advisory Council shall serve without compensation. Sec. 1655. SELF-GOVERNMENT. The Committee may prepare and adopt rules for the conduct of its business and designate the time and place of its meetings. Sec. 1656. DUTIES. The Committee shall act in an advisory capacity to the Director of Health Services in matters relating to the training and certification of Mobile Intensive Care Paramedics. Sec. 1657. ADVISORY COUNCIL. As a part of the Committee a separate advisory council is hereby created to consist of six members. Pursuant to Section 51 of the Charter of the County the Committee shall appoint the six members as follows:
(a) A representative proposed by the Los Angeles County Ambulance Association.
(b) A representative proposed by the Los Angeles County Heart Association.
(c) A representative proposed by the League of California Cities, said representative to be from a participating city and whose assignment is to supervise a Mobile Intensive Care Unit.
(d) A representative from the Communications Department of the County of Los Angeles.
(e) An educator proposed by the Southern California (Continued)
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ORD. NO. 14099 274-10,8146 Eff. 3-22-714 Sec. 1657. (Continued) Association of Community College who is skilled in the area of training of mobile intensive care paramedics.
(f) A practicing Paramedic proposed by the Director of Paramedic Training, County of Los Angeles.
The members of the Advisory Council shall serve for a term of one year from the date of appointment and until their successor is appointed and qualifies, subject, however, to the right of the committee to remove any such member at any time at its pleasure.
The Advisory Council shall act in an advisory capacity to the Committee.
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APPENDIX D
COUNTY OF LOS ANGELES OFFICE OF THE COUNTY COUNSEL
648 HALL OF ADMINISTRATION LOS ANGELES, CALIFORNIA 9OOI2
974 1926 July 10, 1975
Mr. Burke Roche, Executive Secretary Los Angeles County Economy & Efficiency Commission 163 Hall of Administration 500 West Temple Street Los Angeles, California 90012
Re: Recommendations of Economy and Efficiency Commission Concerning the Organization and Operation of the Paramedic Committee
Dear Mr. Roche:
You have asked that we review the subject recommendations, dated July 2, 1975, to determine whether there are any legal impediments which would prevent their implementation. We have completed our review and note that several of the proposals seem contrary to provisions of the Wedworth-Townsend Paramedic Act, hereinafter referred to as “Act” (Health and Safety Code (HSC) Section 1480 et seq.). We refer specifically to those provisions contained in HSC ∋∋1480.1, 1481, 1481.1, and 1484.2.
HSC ∋1480.1 provides:
"The training of mobile intensive care paramedics may only be conducted by a community college, college, university, or hospital that has a certificate of approval for its curriculum and training program from the county health officer of the county in which it is located."
HSC ∋1481 provides:
"As used in this article:
(a) 'Mobile intensive care paramedics' means
personnel who have been trained in the provision of emergency cardiac and noncardiac care in a
John H. Larson, County Counsel Donald K. Byrne, Chief Deputy-
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Mr. Burke Roche -2- July 10, 1975
training program certified by the county health officer of the county giving certification or a certified training program in another county that has been evaluated and approved by the county health officer of the county giving certification, and who pass the performance and written examinations required for certification by the officer as qualified to render the services enumerated in this article in the county giving such certification.
(b) “Mobile intensive care nurse' means a
registered nurse who has been certified by a county health officer as qualified in the provision of emergency cardiac care and noncardiac care and the issuance of emergency instruction to mobile intensive care paramedics.”
“*****”
HSC ∋1481.1 provides:
"The training program for mobile intensive care
paramedics shall consist of a minimum of 200 hours of didactic training, a minimum of 100 hours of clinical experience, and a field internship of at least 200 hours.”
"However, all or any portion of the required
training program for a mobile intensive care paramedic may be waived by the county health officer of the county giving certification if the applicant passes the performance and written examinations required for certification or the appropriate portion of the performance examination.”
HSC ∋1484.2 provides:
"The county health officer shall establish
criteria necessary to maintain certification as a mobile intensive care paramedic or a mobile intensive care nurse including, but not limited to:
(a) A formal program of continuing education.
(b) Continuous service as a mobile intensive care
paramedic or a certified mobile intensive care nurse.
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Mr. Burke Roche -3- July 10, 1975
(c) Retesting at two-year intervals, which shall
include a performance examination and may include written examinations and oral examinations."
These statutory provisions clearly give the county
health officer (our Director of Health Services) exclusive authority (1) to approve mobile intensive care paramedic training programs providing paramedics for his county (if the minimum standards of HSC ∋1481.l are satisfied), (2) to certify all mobile intensive care paramedics and mobile intensive care nurses providing services in his county, and (3) to establish criteria necessary to maintain certification as a mobile intensive care paramedic or nurse.
Under the referenced recommendations, it is proposed that a reorganized Paramedic Committee, whose members would be appointed by the Board of Supervisors, would be given, among other responsibilities, the following duties:
"A. To arbitrate differences between the Department of Health Services and other sectors of the community including but not limited to physicians, private companies, community colleges, municipalities, and hospitals in the field of paramedic services and training.
B. To hear and decide appeals of decisions made by
the Department of Health Services on the following matters:
1. Decisions to establish and enforce policies,
procedures, and standards to control the certification of mobile intensive care nurses and paramedics.
2. Decisions to accept or reject proposals of
any public or private organization to initiate or modify a program of paramedic services or training.
C. To hear and decide appeals of certification
decisions by the Department of Health Services and the certifying officer."
“****”
Decisions reached by the Paramedic Committee could be appealed to the Board of Supervisors.
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Mr. Burke Roche -4- July 10, 1975
The effect of these proposals would be to give the
Paramedic Committee, and finally, the Board of Supervisors, apparent authority to override decisions of the Director of Health Services concerning matters which, by virtue of the cited Health and Safety Code provisions, have been vested by the Legislature solely in the Director. It is, of course, settled that a county possesses only those powers specifically granted by law and those necessarily implied from the powers expressed. San Vincente Nursery School v. County of Los Angeles (l956), l41 Cal. App. 2d 79, 85. It is also settled that where the law prescribes a particular mode by which a county shall exercise a power, that mode must be followed in order to make it a valid exercise of power. Hilton v. Board of Supervisors (1970), 7 Cal. App. 3d 708, 714.
As noted, it is the Wedworth-Townsend Act which sets forth the powers of a county in the paramedic area, and it is the cited provisions of the Act which prescribe the mode by which paramedic training programs, and paramedics and mobile intensive care nurses, are certified. That mode does not provide for decisions relative to such certification to be vested in any public officer other than the county health officer. Accordingly, such decisions by the Paramedic Committee or the Board of Supervisors would be ultra vires, would be illegal, and could not be binding upon the Director of Health Services. Cf. Skidmore v. West (1921), 186 Cal. 212, 217.
Therefore, it will be necessary to amend the Act in order to provide the Paramedic Committee and Board of Supervisors with the necessary authority to make these decisions. If you wish, we would be pleased to assist you in drafting an appropriate amendment.
Sincerely yours, JOHN H. LARSON County Counsel By DANIEL D. MIKESELL, JR. Deputy County Counsel
DDM:ac
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Supplement August 1995
Dennis Jorgensen George W. Kahl Glenn A. Langer, M.D. Kenneth Long John R. MacFaden John H. Mahaffey John W. Mahaffey Gene Mahoney George D. Morgan Muriel M. Morse Gail Pleasance, R.N. J. Walter Schaeffer Edward L. Schindler Joe G. Smith Leslie R. Smith John F. Sturges Mrs. Mary Taylor, Jr. William Trautman Vice President, NewhallAmbulance Inc. Fire Chief, City of Monrovia President, American Heart Association, Greater Los Angeles Affiliate Chief Engineer, Fire Department, City of Los Angeles Executive Vice President, Los Angeles County Ambulance Association President, ANVAL Enterprises Inc. Secretary-Treasurer, ANVAL Enterprises Inc. Chief, Fire Department, City of Arcadia Captain, Paramedic Co-Ordinator, Department of Fire, City of Long Beach General Manager, Personnel Department, City of Los Angeles Instructor, Education Department, Daniel Freeman Hospital President, Schaeffer's Ambulance Service Inc. Assistant Director for Emergency and Disaster Services, Hospital Council of Southern California Chief, Fire Department, City of Inglewood Executive Director, San Pedro and Peninsula Hospital Chief, Fire Department, City of Santa Monica Chairman of the Board, American Heart Association, Greater Los Angeles Affiliate Los Angeles MICU Paramedic, MEDEVAC Paramedic Ambulance Inc.
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-36- Robert B. White Robert F. Woehrman~ Mrs. Betty WriEht, R.N. Howard Zuck San Fernando Valley Area Representative, Los Angeles County Federation of Labor, AFL-CIO Owner, AIDS Ambulance and Medical Service Coordinator-Instructor, EMT and Paramedic Program, Department of
Nursing, Pasadena City ColleEe Assistant General Manager, Personnel Department, City of Los Angeles